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Navigating Politics

In this video, Daniela C. Rodríguez reviews some potential difficulties of working with national governments for disease eradication program success.
RODRIGUEZ: In this section, we’re going to discuss navigating politics. We’re going to talk about what it looks like to work with country governments within national borders and across country settings. Governments have always been seen as the owners and beneficiaries of the polio eradication initiative. In fact, this formal GPEI policy states the polio-affected countries take primary responsibility and ensure accountability for the achievement of the objectives and implementation of the plans. While this is the rhetoric, reality has not always been this way. Polio eradication really operated under a command-and-control leadership for a long time. Before 2010, WHO had a very directive role. They were telling everybody what to do. But this has evolved over time.
Earlier lecturers have touched on some of the catalysts for this evolution, such as changes to the organizational structures and approach that came about when the Gates Foundation joined the GPEI. Also, in practice, not all governments have had the same commitment to polio eradication and not all country health systems have seen clear-cut benefits. Let’s look at this a bit more closely. OK, so let’s start with this. Ask yourself, what role do governments play in the global alliance for polio eradication?
Governments have many roles. They provide high level advocacy in support of the program. They help finance the program. They help strengthen health systems for program delivery, such as strengthening surveillance, or the lab systems, or cold storage. They do resource allocation to subnational areas. And they provide staffing, supervision, and implementation of polio campaigns. As well as other activities, one takeaway here is that a lot is expected of governments in polio eradication. What you see here is an image of the World Health Assembly declaration for polio eradication. The World Health Assembly is the governing body of the WHO. It is made up of representatives from every country in the world, and each country gets one vote.
The World Health Assembly Declaration to eradicate polio was unanimously endorsed in 1988. This did not happen by accident. According to Bill Fahey, who was a smallpox veteran, the World Health Assembly resolution was the result of a lot of work and education that was done with health ministries outside of the organization in order to encourage them to take these responsibilities on. Fahey also pointed out the critical role of Rotarians in advocating across the world for this. Historian Bill Muraskin has argued that work by international actors like Fahey and Jim Graham of UNICEF was less education and more, quote, “an exercise in backroom power politics,” end quote. Either way, achieving adoption of this declaration required considerable work and diplomacy.
So moving to translating this global alliance to local action, what have been some of the challenges and strategies? Country buy-in has been more complex in practice. The World Health Assembly Declaration did not have substantive buy-in from all countries that would be required to undertake polio-eradication efforts. While many governments were willing to give the declaration to eradicate polio a verbal endorsement, they were concerned about trade-offs on the ground. This was especially true in settings where the polio-eradication effort has diverted attention and resources from local priorities. The important thing to consider here are incentives. What were the potential risks and benefits for countries? All countries, of course, would be happy to be rid of polio.
But in practice, many were not ready to make eradication their top priority when there were many other diseases also affecting the populations. Not surprisingly, as polio-eradication goals are missed and deadlines are delayed, maintaining country ownership and attention for polio has been difficult. A question for you is, what is the importance of engaging with national governments and having their buy-in? What strategies could you undertake to have that continued support? And yet, there’s another layer to this as well. Sustained buy-in for polio at subnational levels has been uneven, especially in countries that are decentralized. Even when polio eradication has commitment at the national level, consistent engagement is still required with subnational actors.
In the end, the GPEI is implemented in door-to-door campaigns by local governments, and local governments, in some cases, have fewer reasons to buy into an international goal. Why might this be the case? Take a minute to think to yourself why local governments may resist buying into these kinds of campaigns. So some answers can include that local governments have competing health priorities. For example, polio may cause much less morbidity and mortality than other diseases in their area. Local governments may have competing non-health priorities, such as if there is an unrest or violence, polio may not seem like a top priority. There also may be competing political priorities.
If a local government is led by a different political party than the central government, they may resist national directives for reasons of party politics. Also, unlike national governments, local governments may not have been involved in the decision to take on polio eradication in the first place. And we have examples of how this has played out in practice. For example, in Nigeria, the polio program is owned by the national government. However, the government does not have complete control over the country’s full territory, and it’s contributed to their struggle to achieve polio eradication. In Pakistan, there’s a division between federal and provincial governments on priorities and strategies, which has also contributed to their difficulties controlling polio.
The thing to remember is that the polio program is existing within a larger health system that has other activities and priorities. So even if political leaders are on board, this is not the same as having all workers at all levels on board. Staff at various levels have, in certain times and places, objected to being asked to work on polio eradication for a wide variety of reasons, including concerns over local disease priorities being neglected or concerns unrelated to polio, like delays and salary payments. Resistance to polio-eradication efforts by health systems actors has been overcome, at times, through activities offered by the polio program itself, such as training and quality assurance. Let me ask you this.
How might weak health systems impact governance and implementation of the polio program? Countries with weak health systems and weak management made operational management for polio more difficult, such as managing underperformance, which meant that you had to engage other health systems’ decision makers to be held accountable for results. And resistance to polio vaccination in many countries was driven by political considerations and a lack of trust, primarily where communities questioned why governments were not providing a broader range of services or supporting overall development. Engagement with high level or local leaders played a crucial role in getting buy-in and endorsing campaigns and then often required repeated interventions and was affected by turnover in key positions.
Yet, level of engagement of political leaders may still vary. As we discussed in the section on the World Health Assembly Declaration, there is a difference between agreeing to participate in an eradication goal and being sufficiently committed to see it through if the road gets tough. The last thing we’ll talk about here are cross-border considerations. Cross-border polio efforts can be complicated by porous land borders, such as between Pakistan and Afghanistan or between Nigeria and Niger. These require cooperation between governments for activities to be effective. Sometimes this can end up in a blame game about whose fault a new recent polio case is. In the best cases, it can get governments to work together.
We would like to acknowledge the contribution of these partners in mapping, synthesizing, framing and preparing the content for the module. We would also like to acknowledge the contribution of these partners in providing information, data, and pictures to the module. We would like to acknowledge the support of our funder as well. [INSTRUMENTAL MUSIC]

Daniela C. Rodríguez, DrPH, MPH Bloomberg School of Public Health, Johns Hopkins University, USA

Take a moment to review the article Pakistan, politics and polio. Then reflect on this statement from the lecturer:

“Not surprisingly, as polio-eradication goals are missed and deadlines are delayed, maintaining country ownership and attention for polio has been difficult. A question for you is, what is the importance of engaging with national governments and having their buy-in? What strategies could you undertake to have that continued support?”

What do you think? What strategies could you undertake to have the continued support of national governments? Are there times when you might want to reach out to other partners besides governments?

Post your thoughts in the discussion.

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